Provider Demographics
NPI:1649202789
Name:GEORGE, LAUREL MOODY (MD)
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:MOODY
Last Name:GEORGE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAUREL
Other - Middle Name:HUTCHINSON
Other - Last Name:MOODY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2007 95TH ST
Mailing Address - Street 2:SUITE #LL A
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564
Mailing Address - Country:US
Mailing Address - Phone:630-848-1700
Mailing Address - Fax:630-848-1718
Practice Address - Street 1:2007 95TH ST
Practice Address - Street 2:LL A CHILDRENS HEALTH PARTNERS SC
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564
Practice Address - Country:US
Practice Address - Phone:630-848-1700
Practice Address - Fax:630-848-1718
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036098773208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02223542Medicare UPIN